Challenging therapeutic pessimism: borderline personality disorder and co-morbid substance abuse¹

Abstract

The challenges encountered within public mental health services in New South Wales, Australia, have been well described in recent review documents. New South Wales and Federal government policies clearly outline expectations of evidence-based service delivery. Achieving these expectations in urban settings remains a somewhat haphazard process, while service delivery in rural and remote areas often falls markedly short of satisfactory.

This article describes the almost overwhelming challenges encountered by a mental health team and drug and alcohol service confronted with a consumer with co-morbid borderline personality disorder (BPD) and a multiple substance abuse disorder. While successful evidence-based treatments for BPD have been described in the literature, therapeutic pessimism remains pervasive in many settings. When a consumer presents with a co-morbid substance abuse disorder, clinicians from both mental health and Drug and Alcohol services at times struggle to develop an effective and collaborative response to care.

A brief exploration of the literature describing the use of Dialectical Behaviour Therapy (DBT) for BPD and substance abuse disorders is provided. A case study set in a rural setting follows providing the background for the description of an innovative approach to treatment utilising a DBT-informed approach. The barriers encountered and overcome and the challenges that remain will be outlined in conjunction with a discussion of the opportunities for innovation and creative service delivery that this article raises.

Keywords:

• borderline personality disorder
• co-morbidity
• Dialectical Behaviour Therapy
• rural mental health
• substance abuse
• therapeutic pessimism

Acknowledgement

Acknowledgement is given to Professor Michael Hazelton for his assistance and encouragement.

Notes

1. This article is based on a recent conference presentation delivered at the Northern Rivers Social Development Council ‘Turning the Tide’ held in Kingscliff, New South Wales, Australia.